Perspectives on the Fellowship Training in Cardiac, Thoracic, and Vascular Anesthesia and Critical Care in Europe From Program Directors and Educational Leads Around Europe.

This article reviews fellowship training in adult cardiac, thoracic, and vascular anesthesia and critical care from the perspective of European program initiators and educational leaders in these subspecialties together with current training fellows. Currently, the European Association of Cardiothoracic Anaesthesiology (EACTA) network has 20 certified fellowship positions each year in 10 hosting centers within 7 European countries, with 2 positions outside Europe (São Paulo, Brazil). Since 2009, 42 fellows have completed the fellowship training. The aim of this article is to provide an overview of the rationale, requirements, and contributions of the fellows, in the context of the developmental progression of the EACTA fellowship in adult cardiac, thoracic, and vascular anesthesia and critical care from inception to present. A summary of the program structure, accreditation of host centers, requirements to join the program, teaching and assessment tools, certification, and training requirements in transesophageal electrocardiography is outlined. In addition, a description of the current state of EACTA fellowships across Europe, and a perspective for future steps and challenges to the educational program, is provided.

Preoperative rehabilitation for thoracic surgery.

PURPOSE OF REVIEW: Lung resection provides the best outcome for patients with early stage lung cancer. However, lung cancer surgery carries a significant risk of perioperative complications. Patient risk may be reduced by addressing modifiable risk factors in the preoperative period. We review how this can be achieved through preoperative rehabilitation pathways. RECENT FINDINGS: Cardiorespiratory fitness is an independent predictor of survival for nonsmall cell cancer. Preoperative exercise programmes may improve cardiorespiratory reserve and reduce perioperative complications. Additional benefits may be achieved through interventions such as smoking cessation programmes, correction of anaemia, improvement of nutritional status and improved oral hygiene. These interventions may also have the additional benefit of enabling high-risk patients previously deemed unsuitable for surgery to be optimized to such a degree that they can undergo surgery. These interventions will achieve maximal benefit when delivered early in lung cancer pathways; this requires close collaboration amongst multidisciplinary teams. SUMMARY: Lung cancer surgery carries significant risk of postoperative pulmonary complications. Through integrating prehabilitation interventions into lung cancer pathways, there are opportunities to improve long-term outcomes for patients.

Extracorporeal membrane oxygenation as an alternative to ventilation.

PURPOSE OF REVIEW: Following the recent H1N1 epidemic, there has been renewed interest in using extracorporeal membrane oxygenation (ECMO) as a treatment for acute respiratory failure. Currently, following the advances in technology, ECMO is now recommended as a definitive treatment for acute respiratory failure. However, there have been limited randomized trials and cohort studies evaluating this therapy. RECENT FINDINGS: Currently, results imply that ECMO is superior to conventional ventilation providing lung rest. There is expansion in the indications for ECMO including a bridge to lung transplantation, the use of ECMO in awake patients, liver transplantation, as well as in adult respiratory distress syndrome. This article looks at the current indications and uses. SUMMARY: Further studies are warranted to define and validate the role of ECMO, including studying the pharmacodynamics and pharmacokinetics of patients receiving support. The use of sedatives and antibiotics may be required to be changed significantly. If the incidence of intracerebral haemorrhage can be decreased, then in the author's opinion it may become the first-line treatment for acute respiratory failure.

Update on anaesthetic approach to pulmonary hypertension.

Pulmonary hypertensive patients going for surgery are at significant risk of perioperative morbidity and mortality. They pose a clinically challenging situation for the anaesthetist and strategies to minimize the effects on these patients are discussed. Recent advances have allowed a better understanding of the pathophysiological mechanisms and development of new therapies. We present a framework for preoperative assessment and optimization. An update on the recent advances in medical therapy with calcium channel blockers, prostacyclin analogues, endothelin receptor antagonists and phosphodiesterase-5 inhibitors is provided and relevant anaesthetic concerns highlighted. Key strategies for intraoperative management are presented and we review the options and novel strategies for managing an acute episode of decompensated pulmonary hypertension intraoperatively. Promising new therapies being explored include intraoperative delivery of inhaled milrinone and inhaled prostacyclin analogues.

Perioperative Extracorporeal Cardiopulmonary Resuscitation: The Defibrillator of the 21st Century?: A Case Report.

Veno-arterial-extracorporeal membrane oxygenation (ECMO) for cardiopulmonary resuscitation (ECMO-CPR) has been recommended by new resuscitation guidelines in the United Kingdom. Our recently established yet unfunded ECMO-CPR service has thus far treated 6 patients, with 3 making a good recovery. One patient suffered a catastrophic perioperative complication through glycine absorption and we are in no doubt that she would not have survived without ECMO. We argue for a pragmatic approach to funding of ECMO-CPR because observational evidence suggests superiority over traditional resuscitation and there exists major methodological and ethical barriers to randomized controlled studies. We also call for high-quality observational evidence in the perioperative setting.

Standards for heart valve surgery in a 'Heart Valve Centre of Excellence'.

Surgical centres of excellence should include multidisciplinary teams with specialist expertise in imaging, clinical assessment and surgery for patients with heart valve disease. There should be structured training programmes for the staff involved in the periprocedural care of the patient and these should be overseen by national or international professional societies. Good results are usually associated with high individual and centre volumes, but this relationship is complex. Results of surgery should be published by centre and should include rates of residual regurgitation for mitral repairs and reoperation rates matched to the preoperative pathology and risk.

Dopamine therapy for patients at risk of renal dysfunction following cardiac surgery: science or fiction?

OBJECTIVES: We aimed to evaluate the renoprotective role of renal-dose dopamine on cardiac surgical patients at high risk of postoperative renal dysfunction. The latter included older patients or those with pre-existing renal disease, elevated preoperative serum creatinine (Cr), poor ventricular function, hypertension, diabetes mellitus and unstable angina requiring intravenous therapy. METHODS: Fifty patients undergoing cardiopulmonary bypass (CPB) who fulfilled the entry criteria were prospectively randomized into two groups: Group 1 received a 'renal-dose' (3 microg kg(-1) min(-1)) dopamine infusion starting at anaesthetic induction for 48 h whilst saline infusion acted as placebo in Group 2. The anaesthetic and CPB regimes were standardized. Urinary excretion of retinol binding protein (RBP) indexed to Cr, an accurate and sensitive marker of early renal tubular damage, was assessed daily for 6 days. Additional outcome measures included daily fluid balance, blood urea and serum Cr. Statistical comparisons were made using ANOVA and Mann-Whitney U-test. RESULTS: No significant difference was found between the groups in their age, gender, preoperative NYHA class, ejection fraction, baseline serum Cr and duration of CPB and aortic cross-clamping. Renal replacement therapy was not required in any instance. Both groups demonstrated a similar and significant rise in urinary RBP throughout the study period. Dopamine-treated patients achieved more negative average fluid balance than those on placebo (5 vs. 229 ml, P<0.05). CONCLUSIONS: Renal-dose dopamine therapy failed to offer additional renoprotection to patients considered at increased risk of renal dysfunction after CPB.

Innovative use of Octopus IV stabilizer in cardiac trauma.

We report an innovative use of the Octopus IV cardiac stabilizer in a case of penetrating thoracic injury. In this case, we used the Octopus IV cardiac stabilizer to immobilize the right ventricular outflow tract during the repair of a stab wound. To date, there have been no reports of such an application of the Octopus IV cardiac stabilizer.

Three-dimensional echocardiography is superior to multiplane transoesophageal echo in the assessment of regurgitant mitral valve morphology.

AIMS: Transoesophageal echocardiography (TOE) plays a vital role in the assessment of mitral valve morphology. However, the accuracy of TOE may be limited by inadequate recognition of all segments. We aimed to evaluate the role of three-dimensional (3D) echocardiography in this respect. METHODS AND RESULTS: Seventy-five patients were studied prior to mitral valve repair surgery. A scoring protocol was devised for recognition of the eight Carpentier segments (0=inadequate for analysis, 1=adequate, 2=good). Using surgical findings as the gold standard, TOE and 3D were compared for adequate recognition scores and accurate detection of functional morphology. Adequate recognition was more frequently obtained with 3D imaging (97% of segments by 3D c.f. 90% by TOE; p = 0.000). The major difference was seen at the commissures (adequate scores in 143/150 commissures by 3D c.f. 90/150 by TOE; p = 0.000). 3D matched more closely to surgical findings, achieving exact functional description in 92% of segments vs 79% segments with TOE (p = 0.000). This incremental value of 3D was seen in both commissures and the anterior leaflet but not in the posterior leaflet. CONCLUSIONS: In this study 3D was superior not only for complete recognition of the mitral valve but also for the accurate localisation and identification of pathology.